North Carolina Industrial Commission
Employer's Report of Employee's Injury or
Occupational Disease to the Industrial Commission
To the Employer:
A copy of this Form 19 accompanied by a blank Form 18 must be given to the employee. It does not satisfy the employee's obligation to file a claim. The filing of this report is required by law. This form MUST be transmitted to the Industrial Commission through your Insurance Carrier.
To the Employee:
This Form 19 is not your claim for workers' compensation benefits. To make a claim, you must complete and sign the enclosed Form 18 and mail it to Claims Administration, N.C. Industrial Commission, 4335 Mail Service Center, Raleigh, NC 27699-4335 within two years of the date of your injury or last payment of medical compensation. For occupational diseases, the claim must be filed within two years of the date of disability or the date your doctor told you that you have a work-related disease, whichever is later.

The use of this form is required under the provisions of the Workers' Compensation Act

Incident Report Identifiers:
IC File #
*Emp. Code #
*Carrier Code #
Employer FEIN
Carrier File #

* Required Information

The I.C. File # is the unique identifier for this injury. It will be provided by return letter and is to be referenced in all future correspondence.

Employee Information:

   
Employee's Name    
Address    
City State Zip
Home Telephone Work Telephone
M F
Social Security Number Sex Date of Birth

Employer Information:

Employer's Name Telephone Number
Employer's Address City State Zip

Insurance Carrier Information:

Insurance Carrier Policy Number
Carrier's Address City State Zip
Carrier's Telephone Number Fax Number

Incident Information:

Employer
1.
 Give nature of employer's business
Time
And
Place 		2. Location of plant where injury occurred
County:
Department:
State if employer's premises:
Yes No
3. Date of injury
4. Day of week:
Hour of day:
5. Was employee paid for entire day Yes No
6. Date Disability began:
7. Date you or the supervisor first knew of injury
8. Name of Supervisor:
Person
Injured		 9. Occupation when injured:
10. (a) Time employed by you: (b) Wages per hour:
11. (a) No. of hours worked per day: (b) Wages per day: (c) No. of days worked per week:
(d) Avg. weekly wages with overtime: (e) If board, lodging, fuel or other advantages were furnished in addition to wages, estimated value per day, week or month:
Cause
And
Nature
Of
Injury		 12. Describe fully how injury occurred and what employee was doing when injured:
(Statement made without prejudice and without vouching for correctness of information)
13. List all injuries and specify body part involved (e.g. right hand or left hand):
14. Date and hour returned to work at:
15. If so, at what wages: Per:  
16. At what occupation: 17. Employee's Salary continued in full: Yes No
18. Was employee treated by a physician
Fatal
Cases		 19. Has injured employee died Yes No 20. If so, give date of death (Submit Form 29)
Employer name: Date Completed:
Signed by: Official Title:

OSHA 301 Information:

Case Number from Log: Date Hired: Time Employee began work on date of incident:
If off-site medical treatment provided, answer entire next line.
Name of Facility: Street Address: City:
Zip: Phone: E.R. Visit: Yes No  
Overnight Stay: Yes No
Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.